Learning how to do a good PCR.

[JPINFV]

Hey all,

As an FTO, I frequently have to teach a new employees and paramedic preceptees how to do EMS Documentation. I have a number of recources, documents, etc as well as war stories of documentation gone bad. I wont torture you with all of it.

That said, as I hit the 21 year mark, I am stil a huge fan of SOAP in one form or another. For me it is the gold standard by wich I measure al naritives regardlessof format.

One of my first PO's (probationary employee...AKA a preceptee in an FTEP program) had a lot of difficulty in charting. She took copious notes on our informal discussions and then added it to a little EMS website she ran at the time (long defunct now as she passed away from cancer several years ago).

I have since copied, adapted and otherwise used what she wrote and turned it into one of the first handouts I give my new PO's. It wrks as a good starting point for discussions and teaching on charting.

The documet is attached to this post. I hope this helps.

SOAP Report Guidelines for EMS.doc

My only complaint with a classic SOAP note for EMS is that it overlooks the need to document response and prearrivial information. I don't think that response to treatment really belongs in a "plan" area, and treatments that may be given, but not needed, should be included in the plan section (for example, even if pain medication isn't given, I think there's value in documenting "morphine PRN for pain" in the plan section). The plan section could also be used to document why certain interventions weren't provided ("Immobilization not indicated per NEXUS").

Similarly, what happens if something delays arrival, for example being stuck at an at grade rail road crossing? Those two issues was why I coined the term "Pre-SOAPeD" (Pre= pre-arrival and D=Delta=Change) for my 5 (6 when I get around to the wrap up post) blog posts on documenting.

[Kiwiology]

Does anybody actually care about your dispatch and response information though?

In the "Data" part of our PRF we put down date, vehicle number, dispatch, locate, depart and destination times etc

The rest is strictly clinical information only

[JPINFV]

When you're delayed 10 minutes at a rail road crossing, I imagine it's kinda of important.

[Kiwiology]

When you're delayed 10 minutes at a rail road crossing, I imagine it's kinda of important.

Is there not a more appropriate place to record it than in the clinical record? We have the top part of our PRF which has a block to fill in times etc; I know the US generally uses electronic PRFs so is that information not all transferred across from the CAD system?

Does the ED Reg begin their note with "delayed 30 minutes seeing pt because was taking a big steamy crap?"

If I write down "History of being delayed 10 minutes because the train crossing was closed" the hospital is going to look at us pretty weird.

Granted not everybody works like we do but the clinical record is for clinically important information, what happened on the way while you were getting there is of no value to the hospital, unless you stopped off at the ice cream store, damn that is important, I like my ice cream

Edited October 8, 2011 by kiwimedic

[JPINFV]

I'm going to bet that if there was a significant delay for reasons that could impact patient care, it would matter. Besides, it is very much documented how the patient arrived at the hospital, which could easily be argued that it doesn't matter if EMS brought a patient in or they walked in themselves.

How about, "Unit XYZ dispatched to _____ for ____. Responded ____ [note: I very much consider response/transport status to be an intervention to be based on what information is known to the crew/dispatch]. Delayed at rail road crossing for 5 minutes.

On arrival, pt is a... [insert rest of HPI here].

As far as electronic vs paper PCRs, I'm not sure. I'm only experienced with paper PCRs, and never used dispatch times when documenting. There needs to be one time source for all times documented, be it dispatch times or what time vitals are taken, or what time specific interventions are being administered. Unless you're going to ask dispatch for the time every time you take a set of vital signs, then why would you use dispatch's clock for your various movement times (i.e. alert, en route, arrival, etc)?

More importantly, if movement times aren't clinically important, why document them at all?

[Kiwiology]

Besides, it is very much documented how the patient arrived at the hospital, which could easily be argued that it doesn't matter if EMS brought a patient in or they walked in themselves.

I wouldn't argue its not important how the patient turned up, but it's probably not the most important thing out there.

How about, "Unit XYZ dispatched to _____ for ____. Responded ____ [note: I very much consider response/transport status to be an intervention to be based on what information is known to the crew/dispatch]. Delayed at rail road crossing for 5 minutes.

On arrival, pt is a... [insert rest of HPI here].

Because the hospital doesn't care and it makes no difference to them.

Locally in the top block of our PRF we have a space to give the vehicle number, job type and dispatch/locate/depart/destination times as appropriate. The rest of the informaton such as the address, MPDS code etc are all stored in the CAD system. Your local flavour of patient report form may record them differently.

There needs to be one time source for all times documented, be it dispatch times or what time vitals are taken, or what time specific interventions are being administered. Unless you're going to ask dispatch for the time every time you take a set of vital signs, then why would you use dispatch's clock for your various movement times (i.e. alert, en route, arrival, etc)?

More importantly, if movement times aren't clinically important, why document them at all?

Our MDT touch-screen has options for depart, locate, arrive destination etc so we use those as the basis for our job cycle times.

Of course its important to document when something was done, heck wear a watch

I'm picky about this because nobody wants to read some long, rambling novel full of superflorious information that doesn't have any clinical relevance. I've read some absolutely horrendously rubbish PRFs that go on and on and on like the story that never ends about every little detail and it just makes my eyes bleed. You are writing a clinical record, not a novel.

If you're worried about getting sued or need to CYA then have the call taker record it against the job notes in CAD or something.

For example here is an example of a supposedly "good" narrative (http://lifeunderthelights.com/2009/06/more-on-ems-narrative-reporting/)

Ambulance 1-J-26 dispatched emergent through the 911 system to the scene of a two-vehicle MVC with injuries on a two-lane 55mph rural highway. Upon our arrival we found a "head-on" style collision between two late-model pick-up trucks with heavy damage to both vehicles on their front driver's side. Triage was initiated and this Patient (Pt) was identified as critical. There were four injuries on this scene. The Pt in this report was the restrained driver of a late-model pickup truck with heavy front-end damage and intrusion into the passenger compartment. Pt was pinned in the vehicle upon our arrival with his chest set between the steering wheel and the seat. Pt was conscious, alert, and oriented x 2 with labored breathing but no apparent airway compromise. Fire/Rescue notified of the need for heavy extrication and a Med-Pigeon Helicopter was requested for a scene response. Traffic control and the landing zone referred to Anytown Sherrif's Dept already on scene. Pt was still located in the driver's seat and was able to understand that he had been in a severe car accident. Pt had strong and rapid radial pulses noted but had shallow respirations. Pt was unable to tell us what time or what day it was. C-spine precautions were initiated in the vehicle with a c-collar and manual stabilization as fire/rescue extricated the patient. Extrication took approx. 10min. Patient was removed via backboard and secured with straps, head blocks, and tape. Pt secured on cot. Due to 10min ETA from ther responding helicopter EMS and an estimated 30min transport time to a trauma center, Pt was taken to the ambulance for stabilization. Patient with CC (Chief Complaint) of chest pain and dyspnea. ASSESSMENT: As above. Skin Pale, cool, diaphoretic. Pupils PERRL. No evidence of head trauma. JVD (Jugular Venous Distention) noted. Trachea midline/mobile. Chest with asymmetrical movement to inspiration, markedly decreased breath sounds in both R upper and R lower chest, bruising, abrasions, and what appeared to be a steering wheel imprint left in Pt's chest with other indications of thoracic trauma. ABD tender to palpation in the RUQ and LUQ, not noticeably distended. Pelvis intact. Extrem c weakening peripheral pulses but good motor and sensation. Pt seemed to be becoming increasingly lethargic, confused, and agitated. Pt was loudly complaining of chest pain and diff. breathing, stating that it "hurt to breathe". Pt's Blood Pressure (BP) taken q 5min showed 1^st reading at 134/84, 2^nd reading of 128/92, and 3^rd of 110/98. TREATMENT: As above. Pt placed on 15-LPM o2 via NRB while still in the vehicle. Bilateral IVs started with a 14ga in L AC and a 16ga started in R AC. Both IVs running 1000ml warm NS fast TKO. Pt placed on 5-lead EKG showing S-tach (Sinus Tachycardia) with occasional PVCs. Pt's abrasions and various superficial bleeding controlled c gauze and tape. Due to Pt's increasing dyspnea, narrowing pulse pressures, JVD, and decreased breath sounds on the R side a needle decompression was performed in the R upper chest (beween 2^nd/3^rd intercostals) with 14ga IV cath and flutter valve placed. Pressurized air return noted in syringe upon penetration of the pleural space. Note trends of vital signs. Pt's breathing improved markedly and Pt's LOC began to improve. Pt continuously monitored during and after treatment. Receiving hospital notified of incoming level 1 trauma by MedChannel radio. Med-Pigeon Flight crew arrived and our crew assisted in packaging the patient. Handed over Pt care to flight crew and assisted with transporting the Pt to the waiting helicopter. Care transferred

If I got handed that stack of text on a PRF as an ED nurse or doctor, Clinical Standards Officer or Medical Advisor it would make my brain boil over

Here is what I would write

Hx today restrained driver head on pick up v. pick up RTA approx 55mph ? no LOC

Heavy front end damage to both vehicles w intrusion to passenger compartment

C/O chest pain + dyspnea ? PTX

O/A pinned in vehicle by steering wheel, pale + diaphoretic

Imobilised; moved to ambulance

O/E conscious + alert, unable to state time or day, airway normal, breathing shallow/laboured, circ pulse strong+rapid,

No head trauma, PERRL. no tracheal shift, noted JVD, chest asymetrical, b/s diminished R lobes left clear

Imprint of steering wheel visible on chest

Abdo RLQ/LLQ tender to palp, no visible distention

Pelvis stable

Motor function/ sensation normal

Superficial grazes and scrapes (... where?)

? R PTX ... increasing SOB, decreasing pulse pressure, JVD, increasingly confused + agitated

Decompressed w 14ga needle R side 2/3 ICS w return of air from plueral space

Once decompressed; SOB relieved, improved LOC

Pt transported by HEMS

1200 BP 144/94 PR 120 RR 10 O2 15L NRB ECG sinus tacw w occasional PVC

1202 IV 14ga L AC 16ga R AC

1202 Normal saline IV 2L

1205 BP 128/92

1210 BP 110/98

1210 Needle decompression

I am not the most skilled clinical documentor in the world and I freely admit that, but isin't something like that much more logical and easier to read than a block of text you have to go searching through that is full of superflorious information?

Oh I also note no GCS was seemingly performed, the chest or abdomen were not percussed, no location of the various scares and cuts was given, it wasn't recorded which side of the chest had worse symetery than the other, no respiratory or pulse rates were given, and who still starts two large bore drips with fluid on a trauma patient?

[JPINFV]

Because the hospital doesn't care and it makes no difference to them.

...because the only people who look at a PCR is the people at the hospital?

Of course its important to document when something was done, heck wear a watch

What's the point if one set of times are going to be based off of one clock and another set of times off of another unless you synch your watch every shift?

I'm picky about this because nobody wants to read some long, rambling novel full of superflorious information that doesn't have any clinical relevance. I've read some absolutely horrendously rubbish PRFs that go on and on and on like the story that never ends about every little detail and it just makes my eyes bleed. You are writing a clinical record, not a novel.

Want to read a novel, read the average physician H&P SOAP note. Additionally, two to three sentences isn't going to break the back of a narrative.

For example here is an example of a supposedly "good" narrative (http://lifeunderthel...tive-reporting/)

My problem with that is the physical formatting. The concept that EMS narratives needs to be done with complete sentences and in a single paragraph needs to die.

HPI:

Allergies:

Medications:

Medical History:

Surgical History:

Social History (when pertinent, including sexual history):

Family History (when pertinent):

Review of Systems:

General:

HEENT:

...etc, but not in one continuous mind boggling paragraph.

Here is what I would write

Hx today restrained driver head on pick up v. pick up RTA approx 55mph ? no LOC

Heavy front end damage to both vehicles w intrusion to passenger compartment

C/O chest pain + dyspnea ? PTX

O/A pinned in vehicle by steering wheel, pale + diaphoretic

Imobilised; moved to ambulance

O/E conscious + alert, unable to state time or day, airway normal, breathing shallow/laboured, circ pulse strong+rapid,

No head trauma, PERRL. no tracheal shift, noted JVD, chest asymetrical, b/s diminished R lobes left clear

Imprint of steering wheel visible on chest

Abdo RLQ/LLQ tender to palp, no visible distention

Pelvis stable

Motor function/ sensation normal

Superficial grazes and scrapes (... where?)

What's a "Cric pulse?"

Allergies? Medications? History? Sensation to what (light touch, pain, vibration, etc) and where? Pain besides abdominal pain and chest pain? How about an evaluation of said pain (OPQRST). Examination of the back? Imobilized? How? KED? Backboard? Scoop? Vacuum mattress? Pulse oximetry? Did you administer oxygen (after all, the patient is suffering from dyspnea)?

? R PTX ... increasing SOB, decreasing pulse pressure, JVD, increasingly confused + agitated

Decompressed w 14ga needle R side 2/3 ICS w return of air from plueral space

Once decompressed; SOB relieved, improved LOC

Again, pulse oximetry, recheck lung sounds? Did anything else change besides SOB decreasing and LOC increasing? LOC increased from what to what? The patient went from A/Ox3 (person, place, purpose) to A/O x ? was treated, and then went to A/Ox?

Pt transported by HEMS

1200 BP 144/94 PR 120 RR 10 O2 15L NRB ECG sinus tacw w occasional PVC

1202 IV 14ga L AC 16ga R AC

1202 Normal saline IV 2L

1205 BP 128/92

1210 BP 110/98

1210 Needle decompression

For someone talking about making it organized and logical, why have intro, treatment, assessment, another treatment, disposition, followed by treatments mixed with what doesn't even amount to a full set of vital signs after the first set?

You administered 2 liters of normal saline to a patient who isn't even hypotensive?

I am not the most skilled clinical documentor in the world and I freely admit that, but isin't something like that much more logical and easier to read than a block of text you have to go searching through that is full of superflorious information?

I'm confused. Where did I ever advocate a block of text approach? However, I'd take a block of text approach over half documenting a case any day of the week.

Oh I also note no GCS was seemingly performed, the chest or abdomen were not percussed, no location of the various scares and cuts was given, it wasn't recorded which side of the chest had worse symetery than the other, no respiratory or pulse rates were given, and who still starts two large bore drips with fluid on a trauma patient?

I also noted that you didn't add any of it either. Alternatively, are you trying to say someone else's blog is now my blog?

[Kiwiology]

...because the only people who look at a PCR is the people at the hospital?

No. Let me clarify, it annoys the piss out of me when I see these long, rambling narratives which start off something like "ambulance dispatched at 11am to shady pines nursing home via 911 for patient complaining of shortness of breath which she said she has had for three days prior, on arrival patient sitting up in bed, complaining of shortness of breath and tightness in her chest which felt like her last heart attack"

Your vehicle number, dispatch location, dispatch times, dispatched for (MPDS code or other) should be elsewhere in the PRF or in the CAD system. Two or three sentences won't kill it but there should be somewhere more appropriate to put it than in the clinical note.

I am not sure why I am so friggin picky about it but it just pains the absolute shit out of me

The concept that EMS narratives needs to be done with complete sentences and in a single paragraph needs to die.

I agree, it makes my eyes bleed

What's a "Cric pulse?"

It's what the pulse of the patient did when you shoved a large bore cannulae through his neck

Allergies? Medications? History? Sensation to what (light touch, pain, vibration, etc) and where? Pain besides abdominal pain and chest pain? How about an evaluation of said pain (OPQRST). Examination of the back? Imobilized? How? KED? Backboard? Scoop? Vacuum mattress? Pulse oximetry? Did you administer oxygen (after all, the patient is suffering from dyspnea)?

Again, pulse oximetry, recheck lung sounds? Did anything else change besides SOB decreasing and LOC increasing? LOC increased from what to what? The patient went from A/Ox3 (person, place, purpose) to A/O x ? was treated, and then went to A/Ox?

I just reformatted what was provided in that blog entry the other bloke wrote, I didn't say it was the most medically complete thing in the world infact its horrendously lacking, as you point out

For someone talking about making it organized and logical, why have intro, treatment, assessment, another treatment, disposition, followed by treatments mixed with what doesn't even amount to a full set of vital signs after the first set?

We list interventions, medicines and vital signs last

So for example I might write

# R femur

Hx of falling from 3m high scaffold - landed heavily on R leg heard loud snap, no LOC

O/A pt laying on back on ground, conscious + alert, well perfused

O/E airway normal, breathing fast/deep, circ normal ... blah blah blah

Traction splint, morphine analgesia adequate

Transported- no change

1200 Observations BP 120/80 RR 22 PR 130 GCS 15 (4/5/6) SPO2 100% on air BGL 5mmol/l Pain 8/10

1202 Entonox PO

1205 IV 18ga L hand

1207 Morphine IV 5mg

1210 Observations BP 110/70 PR 100 GCS 15 (4/5/6) Pain 5/10

You administered 2 liters of normal saline to a patient who isn't even hypotensive?

No, that was in the original block of text so I re-wrote it

I'm confused. Where did I ever advocate a block of text approach?

You did not, it's more half of what is in the block of text is irrelevant or it's missing information that is important

I also noted that you didn't add any of it either. Alternatively, are you trying to say someone else's blog is now my blog?

Wasn't in the original for me to write down, and no.I'm not

I suppose what you call dispatch and pre-arrival info we put in the "Data" block of our patient report form, its the same thing I dno, it just annoys me for whatever reason, then when I see all these people writing huge blocks of text which include every detail under the sun my brain starts to boil

For example

Ambulance 1-J-26 dispatched emergent through the 911 system....

Triage was initiated and this Patient (Pt) was identified as critical. .

There were four injuries on this scene.

1. Your vehicle number should be recorded elsewhere

2. Really? Wow, nobody would ever think triage wasn't done on every patient!

3. Thats nice, but we're not talking about them. If it said "front passenger decased" thats important because it shows significant mechanisim of injury but otherwise don't include it

The Pt in this report ...

Fire/Rescue notified of the need for heavy extrication and a Med-Pigeon Helicopter was requested for a scene response.

Traffic control and the landing zone referred to Anytown Sherrif's Dept already on scene.

Pt was able to understand that he had been in a severe car accident.

Extrication took approx. 10min.

Due to 10min ETA from ther responding helicopter EMS and an estimated 30min transport time to a trauma center, Pt was taken to the ambulance for stabilization.

Pt continuously monitored during and after treatment.

Receiving hospital notified of incoming level 1 trauma by MedChannel radio

Med-Pigeon Flight crew arrived and our crew assisted in packaging the patient.

Handed over Pt care to flight crew and assisted with transporting the Pt to the waiting helicopter.

Care transferred.

1. I hope the patient in your PRF is not somebody else's patient, it goes without saying so why include it?

2. Who cares?

3. Who cares?

4. This TELLS us nothing relevant, it INFERRS the patient has a certian level of responsivness or alertness but doesn't say explicitly, so leave it out

5. Who cares?

6. Do you really have to mention you took the patient to the ambulance?

7. Wow, I would hope so! Standard of care anbody? Hey Conrad Murray look over here!

8. Who cares?

9. I bet that makes you feel important!

10. Did you walk back to the ambulance afterwards, better document that too!

11. No really? Did you expect the HEMS Doctor or Paramedic to expect you to keep on looking after him in the helicopter even tho you didn't go with them?

Edited October 8, 2011 by kiwimedic

[EMTDenny]

I was just looking over this post to refresh my memory on PCR and WOW!! amazing advice from all you guys. I decided to comment on this again so it can be on top for the new members or new EMT or hell even people lurking around looking for some advice.

Once again thank you all for this amazing advice and tips.

[Medic211]

What is your opinion on a BLS provider documenting the skills performed by the ALS provider on their PCR ? I have been telling my volunteer ambulance that we don't document what the ALS providers does.